Application Forms
Please download, print and use any relevant application form available here.
Enrollees with Western Digital Technologies GK ,Western Digital Marketing GK
| No. | Application Form | Document | Entry Sample |
Submission |
| Dependent Change Notification (Addition) | PDF |
Entry Sample |
Agent in Charge of WDTJ
APO_Social Insurance Consultants Corporation |
|
| Dependent Certification Record | PDF |
Entry Sample |
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| Dependent Certification Check List | PDF |
Entry Sample |
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| Dependent Change Notification (Removal) | PDF |
Entry Sample |
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| Application for Reissue of Insurance Card Elderly Recipient Certificate Eligibility Certificate for Ceiling-Amount |
PDF |
Entry Sample |
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| Address Change Notification of the Insured Person | PDF |
Entry Sample |
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| Notification for Acquisition of Qualification as an Insured Person with Optional and Continued Insurance | PDF |
Entry Sample |
Western Digital Technologies Health Insurance Association
Yoyogi East 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
|
|
| Application for Purchase of Exclusive Healthy Menu Option Coupons |
PDF |
Entry Sample |
Submission for
application forms
1 through 6
application forms
1 through 6
Agent in Charge of WDTJ
APO_Social Insurance Consultants Corporation
APO_Social Insurance Consultants Corporation
Submission for
application form
7 and 8
application form
7 and 8
Western Digital Technologies Health Insurance Association
Yoyogi East, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
Insured Persons with Optional and Continued Insurance
| No. | Application Form | Document | Entry Sample |
Submission |
| Dependent Change Notification (Optional and Continued Insurance) | PDF |
Entry Sample |
Western Digital Technologies Health Insurance Association
Yoyogi East 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
|
|
| Application for Reissue of Insurance Card Elderly Recipient Certificate Eligibility Certificate for Ceiling-Amount Application (Optional and Continued Insurance) |
PDF |
Entry Sample |
||
| Address Change Notification of the Insured Person (Optional and Continued Insurance) | PDF |
Entry Sample |
||
| Notification for Loss of Qualification as an Insured Person with Optional and Continued Insurance | PDF |
Entry Sample |
Submission for
application forms
9 through 12
application forms
9 through 12
Western Digital Technologies Health Insurance Association
Yoyogi East, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
Standard Application Forms
*Insured persons with optional and continued insurance submit application forms to the Western Digital Technologies Health Insurance Association.
| No. | Application Form | Document | Entry Sample |
Submission |
| Name Change Notification for Insured Person (Dependent) | PDF |
Entry Sample |
Agent in Charge of WDTJ
APO_Social Insurance Consultants Corporation |
|
| Notification of Long-term Care Insurance Exemption | PDF |
Entry Sample |
||
| Notification of Long-term Care Insurance Exclusion | PDF |
Entry Sample |
||
| Application for Payment of Medical Care Costs (Paid in Advance/Therapeutic Devices, etc.) |
PDF |
Entry Sample |
Western Digital Technologies Health Insurance Association
Yoyogi East 5-23-5 Sendagaya,
Shibuya-ku, Tokyo, 151-0051 |
|
| Receipt (Medical Examination) Statement | PDF |
– | ||
| Application for Payment of Medical Care Costs (Acupuncture/Moxibustion) |
PDF |
Entry Sample |
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| Application for Payment of Medical Care Costs (Massages) |
PDF |
Entry Sample |
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| Application for Health Insurance Payment of Funeral Fees (Expenses) for Insured Person or Family Member | PDF |
Entry Sample |
Agent in Charge of WDTJ
APO_Social Insurance Consultants Corporation |
|
| Application for Lump-sum Balance of Childbirth/Childcare Allowance | PDF |
Entry Sample |
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| Application for Payment of Childbirth/Childcare Lump-sum Allowance | PDF |
Entry Sample |
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| Application for Payment of the Childbirth/Childcare Lump-sum Allowance (Substitute Payee System) |
PDF |
Entry Sample |
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| Application for Maternity Allowance | PDF |
Entry Sample |
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| Application for Injury and Illness Allowance | PDF |
Entry Sample |
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| Certificate of Consent | PDF |
– | ||
| Application for Issuance of Health Insurance Eligibility Certificate for Ceiling-Amount | Digital Application System |
Western Digital Technologies Health Insurance Association
Yoyogi East 5-23-5 Sendagaya,
Shibuya-ku, Tokyo, 151-0051 |
||
PDF |
Entry Sample |
|||
| Health Insurance Application for Issuance of Certificate Issued for Specific Disease Treatment | PDF |
Entry Sample |
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| Point Request for Influenza Vaccination Subsidy |
Digital Application System |
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PDF |
Entry Sample |
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| Bank Account Change Notification for Payment Transfers | PDF |
– | ||
| Assistance Application for Medical Treatment to Quit Smoking | PDF |
Entry Sample |
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| Application for Dental Examination Expense Assistance Payment Form | PDF |
Entry Sample |
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Submission for
application forms
13 through 15 and
application forms
20 to 26
application forms
13 through 15 and
application forms
20 to 26
Agent in Charge of
WDTJ
APO_Social Insurance Consultants Corporation
WDTJ
APO_Social Insurance Consultants Corporation
Submissionfor
application forms
16 through 19 and
application forms
27 to 32
application forms
16 through 19 and
application forms
27 to 32
Western Digital Technologies Health Insurance Association
Yoyogi East, 5-23-5 Sendagaya, Shibuya-ku, Tokyo, 151-0051
For more information about the application forms below, please contact the Western Digital Technologies Health Insurance Association (info@wdtj-kenpo.jp).
- Application Forms for Medical Care for Injury or Illness Caused by a Third Party
- Application for Payment of Transportation Costs
- Application forms for overseas medical treatment expenses
- Application for Eligibility Certificate for Ceiling-Amount/Reduction of the Standard Amount of Patient Liability